HomeMy WebLinkAbout2012 RESULTS RETESTS W RCB, January 2002 Page of
Secondary Containment Testing Report Form
This form is intended for use by contractors performing periodic testing of UST ,secondary containment systems. Use the
appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and
printouts from tests (if applicable), should be provided to the, facility owner /operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: MIKE'S FOOD & LIQUOR Date of Testing: 4/20/12
Facility Address: 2300 PANAMA LANE, BAKERSFIELD
Facility Contact: Phone:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector (rf present during testing):
2. TESTING CONTRACTOR INFORMATION
Company Name:
Pass
Technician Conducting Test:
Not
Tested
Credentials: ❑ CSLB Licensed Contractor
❑ SWRCB Licensed Tank Tester
License Type:
Manufacturer
License Number:
Manufacturer Training
Component(s) Date Training Expires
INCON
INCON TS -STS 5/27/12
#1 87 SECONDARY NEW
❑
0
❑
0
3. SUMMARY OF TEST RESULTS
Component
Pass
Fail
Not
Tested
Repairs
Made
Component
Pass
Fail
Not
Tested
Repairs
Made
#1 87 SECONDARY NEW
❑
0
❑
0
❑
❑
❑
0
LINE FROM STP -DISP #1/2
X
❑
❑
❑
❑
❑
0
0
0
0
0
❑
0
0
❑ 1
0
#2 87 SECONDARY OLD
❑
0
❑
❑
❑
0
❑
❑
LINE FROM DISP
❑
❑
❑
❑
❑
❑
❑
❑
41/2- 5/6- 7/8 -3/4
X
❑
❑
❑
❑
❑
❑
0
#3 91 SECONDARY OLD
❑
❑
❑
0
0
❑
❑
❑
LINE FROM DISP
❑
0
❑
0
❑
❑
0
0
41/2- 5/6- 7/8 -3/4
X
❑
❑
❑
❑
1 ❑
Cl
❑
❑
❑
❑
❑
0
❑
❑
❑
❑
❑
0
0
❑
0
❑
❑
If hydrostatic testing was performed, describe what was done with the water after completion of tests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements
Technician's Signature: Date: 4/20/12
S W RCB, January 2002 Page of
5- SECONDARY PIPE TESTING
Test Method Developed By: ❑ Piping Manufacturer ❑ Industry Standard 0 Professional Engineer
0 Other (Specify)
Test Method Used: ❑ Pressure ❑ Vacuum ❑ Hydrostatic
❑ Other (Specify)
Test Equipment Used: Equipment Resolution:
Piping Run #1 -87
Piping Material: PLASTIC
Piping Run 92 -87 Piping Run #3 -91
Piping Run #
PLASTIC
PLASTIC
Piping Manufacturer:
APT
TCI
TO
Piping Diameter:
1.5"
1.5"
1.5"
Length of Piping Run:
52'
60'
60'
Product Stored:
87
87
91
Method and location of
i in -run isolation:
NEW LINE STP TO
DISP # 1/2
DISP # 1/2-5/6-78-3/4
DISP # 1 /2 -5 /6- 718 -3J4
Wait time between applying
pressure /vacuum /water and
starting test:
1 HOUR
1 HOUR
I HOUR
Test Start Time:
1:15
3:45
4:45
Initial Reading (R,):
6.1
5.2
5.1
Test End Time:
2:15
4:45
5:45
Final Reading (RF):
6.1
5.2
5.1
Test Duration:
I HOUR
i HOUR
l HOUR
Change in Reading (RF -R,):
0
0
0
Pass/Fail Threshold or
Criteria:
0
0
0
Test Result:'
X Pass p Fail
X Pass <'' 13 Fail ,'`
X Pass O Fait
Q Pass 0 Fail
Comments — (include information on repairs made prior to testing, and recommended follow -up for failed tests)
740 L f
SB989 TESTING FAILURE REPORT
SITE NAME: MIKE'S FOOD & LIQUOR DATE: 4/20/12
ADDRESS: 2300 PANAMA LANE TECHNICIAN: JAMES RICH
CITY: BAKERSFIELD SIGNATURE:
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE
TESTING.
REPAIRS: Rc,0Lo -� P24�QuAl 1.I./Z 1i W-
ern
Ze
LABOR:
PARTS INSTALLED: Pte' ? ,,•t,�s
NAME: TITLE:
SIGNATURE:
THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING
THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR
THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR
ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF
ANY FINES OR PENALTIES OCCURING FROM NON - COMPLIANCE.
A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR
CONVIENENCE.
RICH ENVIRONMENTAL
5643 BROOKS CT. - BAKERSFIELD, CA 93308
OFF.(661)392 -8687 FAX(661)588 -7808
ACURITE TM PIPELINE TESTER
PRECISION PRODUCT LINE TEST
TEST RESULTS
DATE: 4 -20 -2012
BILLING: MIKE'S FOOD & LIQUOR SITE: MIKE'S FOOD & LIQUOR
2300 PANAMA LANE 2300 PANAMA LANE
BAKERSFIELD, CA BAKERSFIELD, CA
PRODUCT PRODUCT MECHANICAL
PRODUCTS LINE TEST LEAK DETECTORS
UNL -87 FROM STP TO
DISPENSER'/2 - .005 -PASS N/A
COMMENTS
A PRECISION TEST WAS PERFORMED ON PRODUCT LINES AT THE ABOVE LOCATION
USING THE ACURITE TM PIPELINE TESTER. I HAVE REVIEWED THE DATA PRODUCED IN
CONJUNCTION WITH AES PROTOCOL, AND THEREFORE SATISFIES ALL REQUIREMENTS
FOR SUCH TESTING AS SET FORTH BY NFPA- 329 -92 AND USE 40 CFR PART 280.
THE RESULTS OF TESTING ARE SHOWN ON THE FOLLOWING PAGE. INCLUDED WITH
THE REPORT ARE REPRODUCTION OF DATA COMPLIED DURING THE TEST WHICH FORMED
THE BASIS FOR THESE CONCLUSION. THIS INFORMATION IS STORED IN A PERMANENT
FILE IF FUTURE VERIFICATION OF TEST RESULTS IS NEEDED.
1 DECLARE UNDER PENALTY OF PERJURY THAT I AM A LICENSED TANK TESTER IN
THE STATE OF CALIFONIA AND THAT THE INFORMATION CONTAINED IN THIS
REPORT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
TES RTIFIED BY:
r
JAMES J. R CH
MFG# LTN -2245
CERT# 90 -1072
d
RICH ENVIRONMENTAL
5643 BROOKS CT. BAKERSFIELD, CA. 93308
OFFICE (661)392 -8687 FAX (661)392 -0621
ACURITE TM PIPELINE TESTER
TEST RESULTS WORK SHEET
DATE:. !!z /2 J /1�2- W/O #:
FACILITY NAME: AA 1�9 -410 u y/1-
FACILITY ADDRESS: %, 3 v J 10l,v-W
PRODUCT LINE TYPE: FIBERGLASS STEEL ASTI (CIRCLE ONE)
SYSTEM TYPE' RESSURE UC�TION GRAVITY (CIRCLE ONE)
TURBINE MANUFACTURER:
PRODUCT
GRADE
START TIME
INITIAL
READING
00:00 /GPH
END TIME
FINAL
READING
00:00 /GPH
TEST
PRESSURE
�' S.I.
VOLUME
RATE
G.P.H.
RESULTS
PASS
OR
FAIL
(�(IUI. -$�
Al ys
�b
_
, o o S
A55
• 0 5v
. 0 Af
1 CERTIFY THAT THE ABOVE LINE TESTS WERE CONDUCTED ACCORDING TO THE
EQUIPMENT MANUFACTURERS PROCEDURES. THE TEST RESULTS AS LISTED IS TRUE AND
ACCURITE TO THE BEST OF MY KNOWLEDGE.
THE TEST PASS /FAIL STATUS IS DETERMINED USING A THRESHOLD OF 190 ML PER HOUR,
(0.05 G.P.H.), RATE AT 1 h TIMES OPERATING PRESSURE, OR 50 P.S.I. WHICH EVER IS GREATER.
TECHNICIAN: 7sYLN'1�S STATE LICENSE #: "P'6
SIGNATURE: MFG. CERTIFICATION #: 4-rAJ - 2211.5